Addiction – Disease? Willful misconduct? Harm Reduction?; How to be a child.

Welcome to the October edition of Tips and Topics.

In SAVVY, I answer two follow-up questions arising from last month’s edition. The first asks how addiction is compared to other health issues. The second asks about a Harm Reduction approach to addiction versus a “medical model”.

In SKILLS, I have excerpted learning points and comments from several readers who responded to the dialogue about “After a patient is discharged… is there a period of time that patients should have to wait before being readmitted to the clinic?”

In SOUL, I reflect on how children are focused on fun, joy, laughter and full self expression. Then we adults gradually suppress that spontaneity only to devote time, money and energy in personal development workshops to rediscover and reawaken that “inner child”.

savvy

Last month, I took you through the sequence of emails that I exchanged with Steve, a Nurse Practitioner (NP) who posed the following question:

Good AM Doc,

I am a practicing NP prescribing Suboxone (buprenorphine and naloxone) in an Office-Based Opioid Treatment (OBOT). After a patient is being discharged from our clinic they are allowing patients to be readmitted to the clinic with no period of time to wait, sometimes the next week. Is there a period of time that patients should have to wait before being readmitted to the clinic?

Thanks.

Steve

Here are a couple of follow-up questions prompted by September’s Tips and Topics that I am answering in SAVVY this month.

Tip 1

Consider how addiction compares with other illnesses

Here’s the first question:

Can you explain to me how addiction is compared to other health issues, such as cancer, diabetes, high blood pressure? I need to gain some understanding of how this is done.

Thank you for your time.

Mark

My response:

Hi Mark:

Here are some references on addiction:

1. Revamped definition of addiction (September 2019) – American Society of Addiction Medicine (ASAM)

Definition:

ASAM: “Addiction is a treatable, chronic medical disease involving complex interactions among brain circuits, genetics, the environment, and an individual’s life experiences. People with addiction use substances or engage in behaviors that become compulsive and often continue despite harmful consequences.

Prevention efforts and treatment approaches for addiction are generally as successful as those for other chronic diseases.”

2. National Institute on Drug Abuse (NIDA) has promoted addiction as a “brain disease”.

Dr. Alan Leshner, then NIDA Director, noted in 1999, “Although the onset of addiction begins with the voluntary act of taking drugs, the continued repetition of ‘voluntary’ drug taking begins to change into ‘involuntary’ drug taking, ultimately to the point where the behavior is driven by compulsive craving for the drug. This compulsion results from a combination of factors, including in large part dramatic changes in brain function produced by prolonged drug use. This is why addiction is considered a brain disease – one with imbedded behavioral and social context aspects.

(“Science-Based Views of Drug Addiction and Its Treatment,” can be found in The Journal of the American Medical Association (JAMA, 1999; 282:1314-1316) and October 12, 1999 Press Release on Principles of Drug Addiction Treatment: A Research-Based Guide.)

3. “Over the past three decades, a scientific consensus has emerged that addiction is a chronic but treatable medical condition involving changes to circuits involved in reward, stress, and self-control; this has helped researchers identify neurobiological abnormalities that can be targeted with therapeutic intervention…..

Yet the medical model of addiction as a brain disorder or disease has its vocal critics. Some claim that viewing addiction this way minimizes its important social and environmental causes, as though saying addiction is a disorder of brain circuits means that social stresses like loneliness, poverty, violence, and other psychological and environmental factors do not play an important role. In fact, the dominant theoretical framework in addiction science today is the biopsychosocial framework, which recognizes the complex interactions between biology, behavior, and environment.”

(Volkow, Nora D (2018): “What Does It Mean When We Call Addiction a Brain Disorder?” Scientific American blog March 23, 2018.)

4. Preventing Chronic Diseases and Reducing Health Risk Factors

There is a health crisis due to the increasing burden of chronic disease.

• “Today, 7 of the 10 leading causes of death in the United States are chronic diseases, and
• almost 50% of Americans live with at least one chronic illness. People who suffer from chronic diseases such as heart disease, stroke, diabetes, cancer, obesity, and arthritis experience limitations in function, health, activity, and work, affecting the quality of their lives as well as the lives of their families.

Underlying these diseases and conditions are significant health risk factors such as tobacco use and exposure, physical inactivity, and poor nutrition. Engaging in healthy behaviors greatly reduces the risk for illness and death due to chronic diseases.”

5. About 80% of chronic diseases are driven by lifestyle factors such as diet and exercise. Cleveland Clinic

The Bottom Line:

• Addiction is very much a lifestyle illness just like diabetes, hypertension, obesity and cancer (to some extent e.g., nicotine addiction and tobacco use disorder). 
• It develops by lifestyle choices and behavior interacting with genetics, the environment and individual life experiences.
• Changing lifestyle choices and behaviors can stabilize and improve functioning just like they can with diabetes, hypertension, obesity and cancer.
• Behaviors and choices may have started a person on the path to addiction, diabetes, hypertension, obesity and cancer. But once a person has the illness, we have to treat them as illnesses that now have a life of their own.
• Punishing people who have flare-ups of their disease pushes people away from treatment; and doesn’t bring recovery in addiction, diabetes, hypertension, obesity and cancer.

Hope this helps, but let me know if not.

David

Tip 2

Harm Reduction can be compatible with a medical disease model and is not mutually exclusive

Here’s the second question:

Hello Dr. Mee-Lee,

I have a rather broad question for you. I previously was a clinician in the United States, working under a “medical model” framework, which I readily adopted. I adopted the view of addiction as a “chronic relapsing brain disease” and had never questioned this view. I relocated to Canada in 2011 and began to learn more of a “harm reduction” framework, which seems to be the mainstream approach – more-so than in the United States.

Subsequently, I have gone through a bit of a personal “paradigm shift” in how I view addiction, treatment options, and the viability of abstinence for some individuals. Further, I no longer accept the definition of a “medical model”, although I do not deny physiological changes that happen in the brain of the substance user. I have adopted more of a harm reduction approach which “…focuses on the harms from drug use rather than on the use itself. It does not insist on or object to abstinence and acknowledges the active role of the drug user in harm reduction programs”. 

I’d be interested in hearing your opinion of a “harm reduction” approach to substance misuse, and if you believe it is a viable alternative to abstinence-only models? 

Best regards,

J.A.

Registered Clinical Counsellor

British Columbia, Canada

My response:

Hi J.A:

I have written about this before. See what you think about what I have written years ago that still applies.

• In essence, with any chronic illness we are always trying to reduce harm and would never expect that someone would be totally free of elevated blood sugar or blood pressure; or totally non-psychotic, non-depressed, non-manic or free of all anxiety. 
• Abstinence-mandated is a phenomenon of USA’s history of addiction treatment when Alcoholics Anonymous and Twelve Step philosophy stepped into the need to help people with addiction. For the longest time (and still too often today) general health and mental health stigmatized addiction; and provided little or no help or hope for those with addiction. So AA filled the vacuum and produced our tradition of abstinence-only approaches in the USA.
• But I don’t see this as a medical model issue. All chronic illnesses are biopsychosocial and fit with a harm reduction model. Addiction is just like chronic disease management of any disease. 
• If you are uncomfortable with “harm reduction” think of it as “progress not perfection.” See SKILLS in the May 2007 edition.
• A harm reduction approach can emphasize the importance of engaging and attracting people into recovery, rather than sending them away “until they are ready” for abstinence. There is no one way to engage a person. It has to be individualized to what makes sense for that client. The AA slogans of “attraction, not promotion” and helping people to “keep coming back” can be just as powerful in clinical services as well.
• To engage and attract people into recovery it is most effective to be abstinence-oriented, not abstinence-mandated. See SAVVY and SKILLS in the June 2007 edition.

Thanks for writing.

David

skills

There were a number of reader responses that raised worthwhile comments and learning points to share in SKILLS this month. I have excerpted those comments and acknowledged them with permission.

Tip 1

Use the Five whys (or 5 whys) as an iterative interrogative technique to explore the cause-and-effect relationships underlying a particular problem

Three readers appreciated the thought process in the exchange of emails last month:

Reader 1.  “Fabulous dissection of Steve’s question and its origins. Much needed insight for the field.”

Colette Croze

Principal, Croze Consulting and

Vice President, Bay View Improvement Company

Reader 2. Friend and colleague, Scott Boyles, Senior Nartional Training Director, Train for Change echoed that appreciation with more specific guidance and wrote: “Your thought process kinda reminds me of the “5 Whys”.

“The primary goal of the technique is to determine the root cause of a defect or problem by repeating the question “Why?”. Each answer forms the basis of the next question. The “five” in the name derives from an anecdotal observation on the number of iterations needed to resolve the problem.”

So I tried my hand at applying the 5 Whys to this example of a problem:

The patient should have to wait before being readmitted.

Why? – Waiting some period of time to be readmitted helps the person get serious about treatment. (First why)

Why? – The wait time gives them time to think about what they have done wrong. (Second why)

Why? – Using non-prescribed substances and breaking rules is bad behavior. (Third why)

Why? – Patients need some sanction for wilful misconduct to help them change. (Fourth why)

Why? – Addiction is a behavior disorder that is best treated by behavior modification using reward and punishment; sanctions and incentives. (Fifth why, a root cause)

My conclusion about the “root cause”: Addiction is viewed as a behavior disorder needing behavior modification rather than “a treatable, chronic medical disease involving complex interactions among brain circuits, genetics, the environment, and an individual’s life experiences.” (ASAM definition).

Reader 3. “Thank you for sharing this question and response series. I am in the process of renewing my certification and am immersed in online trainings. I am becoming aware of my own knowledge gaps and the need for a more comprehensive understanding of the nature of substance use disorders. Your first two replies seemed to fully make the case for treatment of “addiction” as a medical condition.”

Thank you for your excellent work.

Lily, CADC I

Tip 2

Focus on how to decrease stigma, discrimination and moral judgment and treat addiction and flare-ups as a chronic illness using person-centered, individualized services

Three readers emphasized how there is still stigma and discrimination in addiction treatment:

Reader 1. “Thank you for this. What a terrific reminder; addiction is like any other chronic illness. It is a DISEASE, a chronic illness that is prone to flare-ups and one should not be punished for having any disease. When I got into this field some 25 years ago, addiction was still viewed as a moral failing and though we have come a long way since then, it seems we still have a long way to go to help understand what it means and what it takes to truly help the addict. So, please continue to enlighten those who are still wandering around in the dark.” 

With much appreciation

Rhonda Hart BS LAC

Reader 2. “Hello, many times I have wanted to write you to thank you for your reasonable and evidence informed responses and challenges.

This question about when to allow a discharged client to return and variations of it are at the crux, I believe, of the Addiction treatment system, which often fights against stigmatization and discrimination. The treatment system displays its internalized stigmatization, as well as shows a basic misunderstanding of addictions and the related impacts and behaviours.

I feel very strongly that we need to stop discharging people for proving that they need our services. As a manager, when these questions arise, I typically counter with 2 questions…. What does the client want? … and … How can we find a way to keep him? The times when, for instance, in a residential treatment facility, there seemed to be no choice, considering safety, I have insisted that the discharge be done with kindness and with an invitation to return.

I am also a manager of a Drug Treatment Court (In Canada we added “treatment” to the name) . I know that you frequently talk about Drug Courts and I am always affirmed by your approach. In our program, we have many harm reduction strategies and we never discharge or punish someone for using – we expect it. Our stance is that addiction is not about using as it is a symptom and, therefore, recovery is not merely about stopping use. While we are still bound by abstinence in at least three months prior to graduation (except for alcohol or marijuana), that is not our focus.” 

Robin Cuff, RP

Manager, Acute Care, Centre for Addiction and Mental Health (CAMH) 

Reader 3. “As parents or family members of those misusing substances, we dream of the day they might seek support and treatment for their chronic health condition. And when they finally reach out their hand, they are met with stigma, judgement, and arbitrary barriers to care. We can do better.”

mgb

Reader 4.  “I cannot thank you enough for this month’s tips and topics. I am the Director of clinical services at a residential withdrawal management and treatment facility and we have this conversation DAILY. I have been saying the same things for years now to my team and it is so great to be able to pass along to them that experts agree that relapse-relapse-kick out is NOT the way to help. Flare up-Flare up-Rethink the treatment plan is a much better approach. Thank You!”

Katie Kimmerling, LIMHP, LADC, Director of Clinical Services

The Bridge Behavioral Health, Lincoln Nebraska

Tip 3

Effective supervision is necessary to help counselors and clinicians examine biases and attitudes and increase their portfolio of treatment approaches and skills.

A reader raised the issue of supervision and the need to broaden skills and approaches in addiction treatment:

Reader 1. “I liked this. What you’re offering the Nurse Practitioner (NP) is supervision. As the middle person between direct services and management, the MAT supervisor has the responsibility to help the NP develop an increased portfolio of treatment approaches and skills. Also, that supervisor has the responsibility to inform management, not just the clinical director, of the need to review treatment policies to determine if they include best practices for the population being served.

I know you aren’t surprised that there is a heavy punitive undercurrent in their care approaches. That’s still around as we continue to encounter blacks and people of color (POC) in drug treatment programs.

Also missing is worker self-analysis. It’s hard to answer your questions if clinicians never looks at themselves and how they feel and think about the patients they treat.

Last, it seems that many treatment providers are entering this treatment specialty with only 1 bow in their quiver. I don’t see it as entirely their fault because of the ways that behavioral treatment is presented as the be-all and end-all of treatment. And when it doesn’t work, it’s the clients who are sanctioned.

There’s a lot wrong with drug treatment. That’s been a problem for many decades and appears to still be a problem now.”

Thanks for your attention,

Ellarwee Gadsden, Ph.D.

Ellarwee’s Elegies, LLC – President

Orange Park, Florida

soul

In July, my two grandgirls and their parents moved to Hawaii from Southern California. So visiting them is no longer an easy car ride or short plane trip but rather at least 5-6 hours in a plane; and in the era of COVID-19, proof of a negative test to enter “paradise”. This means that my travel schedule will have a lot of Hawaiian vacations to be with the girls for their birthdays and for the holidays.

I’m not complaining and I don’t expect any sympathy.

I am spending a lot of time with an 8 and 6 year old as you don’t come all this way for a couple of days. Here are some observations and reflections as I am around them all the time:

• Children are always looking for fun, joy, laughter and excitement.
• They not self-conscious about fully expressing themselves – they scream with delight; yell in excitement; and run around in a manic frenzy.
• They sing and laugh out loud whenever they want.
• Their next question is always “What shall we play now?”

Then we adults gradually start suppressing such child-ish behavior:

• “You can’t just have fun all the time. Work hard; no pain, no gain.”
• “Shh, be quiet. Lower your voice. Sit still. Don’t make a fool of yourself.”
• Only sing in the shower and laugh out loud (lol) in text messages and emails.
• Your next question should be “What job can I do for you now?” You can’t just play all the time: do your homework and chores.

I know different ages require attention to different developmental stages and tasks. But how do we not throw out the baby with each developmental bath water? How do we preserve the joy of childhood while helping them become socialized in the world of grown-ups?

The sad but true reflection is how adults spend thousands of dollars on personal development and growth workshops to un-learn old adult patterns and re-learn how to be child-ish all over again.

So I asked my 8 and 6 year old grandgirls what would be the steps they would teach adults about how to be like a ‘kid’ again.

Here are the steps my 6 year old granddaughter listed about playing in the rain like a child:

1. Go outside.

2. Splash in puddles.

3. Stay outside in the rain.

4. Don’t use an umbrella.

Here are the steps my 8 year old granddaughter listed about how to be like a child:

1. Don’t use or carry mobile phones or computers.

2. Play with nature outside e.g., watch a stick float and speed along with each ‘breaking’ surf wave; or imagine leaves are vegetables in that make believe dinner party.

3. Run wildly around – doing that barefoot is optional.

4. Scream loudly with excitement.­­­

All advice and steps are free and could save you thousands of dollars. You won’t need that “Discover your inner child” workshop anymore.